Caesarean section

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Caesarian section
Intervention
Cesarian the moment of birth3.jpg
A team performing a Caesarean section.
ICD-10-PCS 10D00Z0
ICD-9-CM 74
MeSH D002585
MedlinePlus 002911
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Caesarian section, also commonly known as C-section and other spellings, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies. A Caesarean section is often performed when a vaginal delivery would put the baby's or mother's life or health at risk. Some are also performed upon request without a medical reason to do so.[1] The World Health Organization recommends that they should be done based only on medical need.[2]

C-sections result in a small overall increase in poor outcomes, in low risk pregnancies.[3] The poor outcomes that occur with C-sections, differ from those that occur with vaginal delivery. Established guidelines recommend that caesarean sections not be used before 39 weeks without a medical indication to perform the surgery.[4]

In 2012 about 23 million C-sections were done globally.[5] In some countries, C-section procedures are used more frequently than is necessary, and consequently governments and health organizations promote programs to reduce the use of c section in favor of vaginal delivery.[6] The international healthcare community has considered the rate of 10% and 15% to be ideal for caesarean sections.[2] Some evidence supports a higher rate of 19% may result in better outcomes.[5] The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881.[7]

Uses

A 7-week old Caesarean section scar and linea nigra visible on a 31-year-old mother.

Caesarean section is recommended when vaginal delivery might pose a risk to the mother or baby. C-sections are also carried out for personal and social reasons. Systematic reviews have found no strong evidence about the impact of caesareans for non-medical reasons.[8][9] Recommendations encourage counseling to identify the reasons for the request, addressing anxieties and information, and encouraging vaginal birth.[8][10] Elective cesareans at 38 weeks showed increased health complications in the newborn.[11] Planned caesarean sections also known as elective caesarean sections should not be scheduled before 39 weeks gestational age unless there is a medical reason to do so.

Medical uses

Some medical indications are below. Not all of the listed conditions represent a mandatory indication, and in many cases the obstetrician must use discretion to decide whether a Caesarean is necessary.

Complications of labor and factors impeding vaginal delivery, such as:

Other complications of pregnancy, pre-existing conditions and concomitant disease, such as:

  • pre-eclampsia[12]
  • previous (high risk) fetus
  • HIV infection of the mother
  • Sexually transmitted diseases, such as genital herpes (which can be fatal to the baby if the baby is born vaginally)
  • previous classical (longitudinal) Caesarean section
  • previous uterine rupture
  • prior problems with the healing of the perineum (from previous childbirth or Crohn's disease)
  • Bicornuate uterus
  • Rare cases of posthumous birth after the death of the mother

Other

  • Lack of obstetric skill—obstetricians not being skilled in performing breech births, multiple births, etc. (In most situations women can birth vaginally under these circumstances, although planned C-section has a lower risk of infant death for breech births than vaginal delivery.[13] Obstetricians are not always trained in proper procedures for such deliveries, increasing the risk still further.)[14]
  • Improper Use of Technology (Electric Fetal Monitoring [EFM])[14][15]

Prevention

It is generally agreed that the prevalence of C-section is higher than needed in many countries and physicians are encouraged to actively lower the rate.[citation needed] Some of these efforts include: emphasizing that a long latent phase of labor is not abnormal and thus not a justification for C-section; changing the start of active labor from a cervical dilation of 4 cm to a dilation of 6 cm; and allowing at least 2 hours of pushing for women who have previously given birth and 3 hours of pushing for women who have not previously given birth before labor arrest is considered.[3] Physical exercise during pregnancy also decreases the risk.[16]

Risks

Adverse outcomes in low risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of C-section deliveries.[3]

Risks to the mother

In those who are low risk, the risk of death for Caesarian sections is 13 per 100,000 and for vaginal birth 3.5 per 100,000 in the developed world.[3] The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth.[17]

In Canada the difference in bad outcome in the mother (e.g. cardiac arrest, wound hematoma, or hysterectomy) was 1.8 additional cases per 100 or three times the risk.[18]

Transvaginal ultrasonography of a uterus years after a Caesarean section, showing the characteristic scar formation in its anterior part.

As with all types of abdominal surgeries, a Caesarean section is associated with risks of postoperative adhesions, incisional hernias (which may require surgical correction) and wound infections.[19] If a Caesarean is performed under emergency situations, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the anaesthesia risk.[20] Other risks include severe blood loss (which may require a blood transfusion) and postdural-puncture spinal headaches.[19]

Women who had Caesarean sections were more likely to have problems with later pregnancies, and it is recommended that women who want larger families should not seek an elective Caesarean. The risk of placenta accreta, a potentially life-threatening condition, is 0.13% after two Caesarean sections, but increases to 2.13% after four and then to 6.74% after six or more. Along with this is a similar rise in the risk of emergency hysterectomies at delivery.[21]

Mothers can experience increased incidence of postnatal depression, and can experience significant psychological birth trauma and ongoing birth-related post-traumatic stress disorder after obstetric intervention during the birthing process.[22] Factors like pain in first stage of labor, feelings of powerlessness, intrusive emergency obstetric intervention are important in the development of birth trauma.[22]

Subsequent pregnancies

Women who have had a Caesarean for any reason are somewhat less likely to become pregnant or give birth again as compared to women who have previously delivered only vaginally.[23]

Women who had just one previous Caesarean section are more likely to have problems with their second birth.[3] Delivery after previous Caesarean section is by either of two main options:

  • Vaginal birth after Caesarean section (VBAC)
  • Elective repeat Caesarean section (ERCS)

Both have higher risks than a vaginal birth with no previous Caesarean section. Criteria for making VBAC include that the previous Caesarean section should be a low transverse one. VBAC (compared to ERCS) confers a higher risk for mainly uterine rupture and perinatal death of the child.[24] Furthermore, 20% to 40% of attempts at VBAC end up resulting in Caesarean section being performed anyway, with greater risks of complications in an emergent repeat Caesarean section than in an ERCS.[25][26] On the other hand, VBAC confers less maternal morbidity and a decreased risk of complications in future pregnancies than ERCS.[27]

Adhesions

Suturing of the uterus after extraction.
Closed Incision for low transverse abdominal incision after stapling has been completed.

There are number of steps that can be taken during abdominal or pelvic surgery to minimize postoperative complications, such as the formation of adhesions. Such techniques and principles may include:

• Handling all tissue with absolute care
• Using powder-free surgical gloves
• Controlling bleeding
• Choosing sutures and implants carefully
• Keeping tissue moist
• Preventing infection

However, despite these proactive measures, abdominal or pelvic surgery can result in trauma that can lead to adhesions. In order to prevent adhesions from forming following a pelvic (gynecologic) surgery, such as hysterectomy, myomectomy or caesarean section, adhesion barrier can be placed during surgery to minimize the risk of adhesions between the uterus and ovaries, the small bowel, and almost any tissue in the abdomen or pelvis.

Adhesions can cause complications, such as:

Infertility, which may result when adhesions twist the tissues of the ovaries and tubes, blocking the normal passage of the egg (ovum) from the ovary to the uterus. One in five infertility cases is estimated to be adhesion related (stoval)
• Chronic pelvic pain, which may result when adhesions are present in the pelvis. Almost 50 percent of chronic pelvic pain cases are estimated to be adhesion related (stoval)
• Small bowel obstruction – the disruption of normal bowel flow, which can result when adhesions twist or pull the small bowel.

Risks to the child

Non-medically indicated (elective) childbirth before 39 weeks gestation "carry significant risks for the baby with no known benefit to the mother." Complications from elective caesarean before 39 weeks include: newborn mortality at 37 weeks may be up to 3 times the number at 40 weeks, and was elevated compared to 38 weeks of gestation. These “early term” births were also associated with increased death during infancy, compared to those occurring at 39 to 41 weeks ("full term").[28] Researchers in one study and another review found many benefits to going full term, but “no adverse effects” in the health of the mothers or babies.[28][29]

The American Congress of Obstetricians and Gynecologists and medical policy makers review research studies and find increased incidence of suspected or proven sepsis, RDS, hypoglycemia, need for respiratory support, need for NICU admission, and need for hospitalization > 4–5 days. In the case of caesarean sections, rates of respiratory death were 14 times higher in pre-labor at 37 compared with 40 weeks gestation, and 8.2 times higher for pre-labor caesarean at 38 weeks. In this review, no studies found decreased neonatal morbidity due to non-medically indicated (elective) delivery prior to 39 weeks.[28]

For otherwise healthy twin pregnancies where both twins are head down a trial of vaginal delivery is recommended at between 37 and 38 weeks.[8][30] Vaginal delivery in this case does not worsen the outcome for the infant as compared with Caesarean section.[30] There is controversy on the best method of delivery where the first twin is head first and the second is not.[30] When the first twin is not head down a C-section is often recommended.[30] Regardless of birth by section or vaginally, the medical literature recommends delivery of dichorionic twins at 38 weeks, and monochorionic twins (identical twins sharing a placenta) by 37 weeks due to the increased risk of stillbirth in monochorionic twins who remain in utero after 37 weeks.[31][32] The consensus is that late preterm delivery of monochorionic twins is justified because the risk of stillbirth for post-37 week delivery is significantly higher than the risks posed by delivering monochorionic twins near term (i.e., 36–37 weeks).[33]

The consensus concerning monoamniotic twins (identical twins sharing an amniotic sac), the highest risk type of twins, is that they should be delivered by caesarean section at or shortly after 32 weeks.[34][35][36]

In a research study widely publicized, singleton children born earlier than 39 weeks may have developmental problems, including slower learning in reading and math.[37]

Other risks include:

  • Wet lung: Retention of fluid in the lungs can occur if not expelled by the pressure of contractions during labor.[38]
  • Potential for early delivery and complications: Preterm delivery is possible if due-date calculation is inaccurate. One study found an increased complication risk if a repeat elective Caesarean section is performed even a few days before the recommended 39 weeks.[39]
  • Higher infant mortality risk: In C-sections performed with no indicated risk (singleton at full term in a head-down position), the risk of death in the first 28 days of life has been cited as 1.77 per 1,000 live births among women who had C-sections, compared to 0.62 per 1,000 for women who delivered vaginally.[40]

Classification

Caesarean sections have been classified in various ways by different perspectives.[41] One way to discuss all classification systems is to group them by their focus either on the urgency of the procedure, characteristics of the mother, or as a group based on other, less commonly discussed factors.[41]

It is most common to classify c-sections by the urgency of performing them.[41] When there is something unusual about the mother or the pregnancy, then it becomes common to classify that c-section by whatever unusual characteristics are seen.[41] When discussing the actual technique or surgical conditions, then c-sections are classified by those techniques.[41]

By urgency

Conventionally, caesarean sections are classified as being either an elective surgery or an emergency surgery.[42] Classification is used to note a strategy for using anesthesia, as in emergencies general anesthesia must be used but when time is available, it is preferable to use regional anesthesia.[42]

A planned caesarean (or elective/scheduled caesarean), arranged ahead of time, is most commonly arranged for medical reasons and ideally as close to the due date as possible.[citation needed] A crash/emergent/emergency Caesarean section is performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, child(ren) or both.[citation needed]

A planned or elective caesarean section is an elective surgery, meaning that it is scheduled in advance rather than performed because of an unscheduled emergency. This confers the ability to perform the delivery at a time when hospital resources are optimal, such as at daytime rather than what might otherwise turn out to be at night. The cost to the patient and the baby for unnecessary surgery may be substantial. Critics also argue that because physicians and institutions may benefit by reducing night time and weekend work, that an inappropriate incentive exists to suggest elective surgery.[43]

Elective caesarean sections may be performed on the basis of an obstetrical or medical indication, or because of a non-indicated maternal request.[8] Among women in the United Kingdom, Sweden and Australian about 7% preferred C-section as a method of delivery.[8] In cases without medical indications the American Congress of Obstetricians and Gynecologists recommend a planned vaginal delivery.[44] The National Institute for Health and Care Excellence recommends that if after a women has been provided information on the risk of a planned C-section and she still insists on the procedure it should be provided.[8] If provided this should be done 39 weeks of gestation or later.[44]

By characteristics of the mother

Caesarean delivery on maternal request

Caesarean delivery on maternal request (CDMR) is a medically unnecessary caesarean section, where the conduct of a childbirth via a caesarean section is requested by the pregnant patient even though there is not a medical indication to have the surgery.[45]

After previous Caesarean

Mothers who have previously had a caesarean section are more likely to have a c-section for future pregnancies than mothers who have never had a c-section. There is discussion about the circumstances under which women should have a vaginal birth after a previous caesarean.

Vaginal birth after caesarean (VBAC) is the practice of birthing a baby vaginally after a previous baby has been delivered through caesarean section (surgically).[46] According to The American Congress of Obstetricians and Gynecologists (ACOG), VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies.[47] According to the American Pregnancy Association, 90% of women who have undergone caesarean deliveries are candidates for VBAC.[25] Approximately 60-80% of women opting for VBAC will successfully give birth vaginally, which is comparable to the overall vaginal delivery rate in the United States in 2010.[25][26][48]

Twins

For otherwise healthy twin pregnancies where both twins are head down a trial of vaginal delivery is recommended at between 37 and 38 weeks.[8][30] Vaginal delivery in this case does not worsen the outcome for the infant as compared with C-section.[30] There is controversy on the best method of delivery where the first twin is head first and the second is not.[30] When the first twin is not head down, a C-section is often recommended.[30] Although the second twin typically has a higher frequency of problems, it is not known if a planned C-section affects this.[8] It is estimated that 75% of twin pregnancies in the United States were delivered by Caesarean section in 2008.[49]

Breech birth

A breech birth is the birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation. In breech presentation, fetal heart sounds are heard just above the umbilicus.

The bottom-down position presents some hazards to the baby during the process of birth, and the mode of delivery (vaginal versus Caesarean) is controversial in the fields of obstetrics and midwifery.

Though vaginal birth is possible for the breech baby, certain fetal and maternal factors influence the safety of vaginal breech birth. The majority of breech babies born in the United States are delivered by Caesarean section as studies have shown increased risks of morbidity and mortality for vaginal breech delivery, and most hospital policies do not permit vaginal breech birth for this reason. As a result of reduced numbers of vaginal breech deliveries, most obstetricians do not receive training in the skill set required for safe vaginal breech delivery anymore.

Resuscitative hysterotomy

A resuscitative hysterotomy, also known as a peri-mortem Caesarean delivery, is an emergency Caesarean delivery carried out where maternal cardiac arrest has occurred, to assist in resuscitation of the mother by removing the aortocaval compression generated by the gravid uterus. Unlike other forms of Caesarean section, the welfare of the fetus is a secondary priority only, and the procedure may be performed even prior to the limit of fetal viability if it is judged to be of benefit to the mother.

Other ways, including by surgery technique

There are several types of Caesarean section (CS). An important distinction lies in the type of incision (longitudinal or latitudinal) made on the uterus, apart from the incision on the skin.

  • The classical Caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today, as it is more prone to complications.
  • The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.
  • An unplanned Caesarean section is performed once labour has commenced due to unexpected labor complications.
  • A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.
  • Traditionally, other forms of Caesarean section have been used, such as extraperitoneal Caesarean section or Porro Caesarean section.
  • A repeat Caesarean section is one that is done when a patient had a previous Caesarean section. Typically it is performed through the old scar.

The EXIT procedure is a specialized surgical delivery procedure used to deliver babies who have airway compression.

The Misgav Ladach method is a modified caesarean section which has been used nearly all over the world since the 1990s. It was described by Michael Stark, the president of the New European Surgical Academy, at the time he was the director of Misgav Ladach, a general hospital in Jerusalem. The method was presented during a FIGO conference in Montréal in 1994[50] and then distributed by the University of Uppsala, Sweden, in more than 100 countries. This method is based on minimalistic principles. He examined all steps in caesarean sections in use, analyzed them for their necessity and, if found necessary, for their optimal way of performance. For the abdominal incision he used the modified Joel Cohen incision and compared the longitudinal abdominal structures to strings on musical instruments. As blood vessels and muscles have lateral sway, it is possible to stretch rather than cut them. The peritoneum is opened by repeat stretching, no abdominal swabs are used, the uterus is closed in one layer with a big needle to reduce the amount of foreign body as much as possible, the peritoneal layers remain unsutured and the abdomen is closed with two layers only. Women undergoing this operation recover quickly and can look after the newborns soon after surgery. There are many publications showing the advantages over traditional caesarean section methods. However, there is an increased risk of abruptio placenta and uterine rupture in subsequent pregnancies for women who underwent this method in prior deliveries.[51][52]

Technique

Pulling out the baby
Illustration depicting Caesarean section.

Antibiotic prophylaxis is used before an incision.[53] The uterus is incised, and this incision is extended with blunt pressure along a cephalad-caudad axis.[53] The infant is delivered, and the placenta is then removed.[53] The surgeon then makes a decision about uterine exteriorization.[53] Single-layer uterine closure is used when the mother does not want a future pregnancy.[53] When subcutaneous tissue is 2 cm thick or more, surgical suture is used.[53] Discouraged practices include manual cervical dilation, any subcutaneous drain, or supplemental oxygen therapy with intent to prevent infection.[53]

Caesarean section can be performed with single or double layer suturing of the uterine incision.[54] A Cochrane review came to the result that single layer closure compared with double layer closure was associated with a statistically reduction in mean blood loss.[55] Standard procedure includes the closure of the peritoneum. However, research questions this may not be needed, with some studies indicating peritoneal closure is associated with longer operative time and hospital stay.[56]

In many hospitals, especially in Argentina, the United States, United Kingdom, Canada, Norway, Sweden, Finland, Australia, and New Zealand, the mother's partner is encouraged to attend the surgery to support the mother and share the experience. The anaesthetist will usually lower the drape temporarily as the child is delivered so the parents can see their newborn.[citation needed]

Anaesthesia

Both general and regional anaesthesia (spinal, epidural or combined spinal and epidural anaesthesia) are acceptable for use during Caesarean section. Regional anaesthesia is preferred as it allows the mother to be awake and interact immediately with her baby.[57] Other advantages of regional anesthesia include the absence of typical risks of general anesthesia: pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and esophageal intubation.[58]

Regional anaesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anaesthesia being the most commonly used regional techniques in scheduled Caesarean section.[59] Regional anaesthesia during Caesarean section is different from the analgesia (pain relief) used in labor and vaginal delivery. The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense nerve block. The dermatomal level of anesthesia required for Caesarean delivery is also higher than that required for labor analgesia.[58]

General anesthesia may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia. General anesthesia is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia.

Prevention of complications

Postpartum infection is one of the main causes of bad outcomes[8][60] and death around childbirth, accounting for around 10% of maternal deaths globally.[61] Caesarean section greatly increases the risk of infection and associated morbidity (estimated to be between 5 and 20 times as high).[60] Infection can occur in around 8% of women who have caesareans,[8] largely endometritis, urinary tract infections and wound infections.

Women who have caesareans need to understand the signs of fever that indicate the possibility of wound infection.[8] Antibiotic prophylaxis is effective for endometritis, preventing as many as 3 out of 4 cases.[8][60] Taking antibiotics before skin incision rather than after cord clamping reduces the risk for the mother, without increasing adverse effects for the baby.[8][62] Whether a particular type of skin cleaner improves outcomes in unclear.[63]

Some doctors believe that during a caesarean section, mechanical cervical dilation with a finger or forceps will prevent the obstruction of blood and lochia drainage, and thereby benefit the mother by reducing risk of death.[64] The available clinical evidence is not sufficient to draw a conclusion on the effect of this practice.[64]

Recovery

Abdominal, wound and back pain can continue for months after a caesarean section, with some evidence that non-steroidal anti-inflammatory drugs are helpful.[8] Women who have had a caesarean are more likely to experience pain that interferes with their usual activities than women who have vaginal births, although by six months there is generally no longer a difference.[65] However, pain during sexual intercourse is less likely than after vaginal birth, although again, by six months there is no difference.[8]

There may be a somewhat higher incidence of postnatal depression in the first weeks after childbirth for women who have caesarean sections, but this difference does not persist.[8] Some women who have had caesarean sections, especially emergency caesareans, experience post-traumatic stress disorder.[8]

Usage

In the United Kingdom, in 2008, the Caesarean section rate was 24%.[66] In Ireland the rate was 26.1% in 2009.[67] The Canadian rate was 26% in 2005–2006.[68] Australia has a high Caesarean section rate, at 31% in 2007.[69] In the United States the rate of C-section is around 33% and varies from 23% to 40% depending on the state in question.[3]

In Italy the incidence of Caesarean sections is particularly high, although it varies from region to region.[70] In Campania, 60% of 2008 births reportedly occurred via Caesarean sections.[71] In the Rome region, the mean incidence is around 44%, but can reach as high as 85% in some private clinics.[72][73]

With nearly 1.3 million stays, Caesarean section was one of the most common procedures performed in U.S. hospitals in 2011. It was the second-most common procedure performed for people ages 18 to 44 years old.[74] Caesarean rates in the U.S. have risen considerably since 1996.[75] The procedure increased 60% from 1996 to 2009. In 2010, the Caesarean delivery rate was 32.8% of all births (a slight decrease from 2009's high of 32.9% of all births).[76] A study found that in 2011, women covered by private insurance were 11% more likely to have a caesarean section delivery than those covered by Medicaid.[77]

China has been cited as having the highest rates of C-sections in the world at 46% as of 2008.[78]

Studies have shown that continuity of care with a known carer may significantly decrease the rate of Caesarean delivery[79] but there is also research that appears to show that there is no significant difference in Caesarean rates when comparing midwife continuity care to conventional fragmented care.[80]

More emergency Caesareans—about 66%—are performed during the day rather than during the night.[81]

The rate has risen to 46% in China and to levels of 25% and above in many Asian, European and Latin American countries.[82] The rate has increased in the United States, to 33% of all births in 2012, up from 21% in 1996.[3] Across Europe, there are differences between countries: in Italy the Caesarean section rate is 40%, while in the Nordic countries it is 14%.[83]

Increasing use

In the United States C-section rates have increased from just over 20% in 1996 to 33% in 2011.[3] This increase has not resulted in improved outcomes resulting in the position that C-sections may be done too frequently.[3]

The World Health Organization officially withdrew its previous recommendation of a 15% C-section rates in June 2010. Their official statement read, "There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them."[84]

The US National Institutes of Health says rises in rates of Caesarean sections are not, in isolation, a cause for concern, but may reflect changing reproductive patterns: "The World Health Organization has determined an “ideal rate” of all caesarean deliveries (such as 15 percent) for a population. One surgeon's opinion[who?] is that there is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. Goals for achieving an optimal caesarean delivery rate should be based on maximizing the best possible maternal and neonatal outcomes, taking into account available medical and health resources and maternal preferences. This opinion is based on the idea that if left unchallenged, optimal caesarean delivery rates will vary over time and across different populations according to individual and societal circumstances."[45]

Some have speculated that caesarean section rates have increased due to a relationship between birth weight and maternal pelvis size, positing on the basis of Darwinian-inspired logic that since the advent of successful Caesarean birth over the last 150 years, more mothers with small pelvises and babies with large birth weights have survived and contributed to these traits. Historically disproportion in childbirth was caused by maternal malnutrition in childhood, in particular malformed pelvic bones due to childhood rickets and the increasing the evolutionary fitness of those persons possessing the phenotype of small pelvis, would not in those cases necessarily lead to a selection for a small pelvis genotype.[85]

History

Successful Caesarean section performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879.

The mother of Bindusara (born c. 320 BCE, ruled 298 – c.272 BCE), the second Mauryan Samrat (emperor) of India, accidentally consumed poison and died when she was close to delivering him. Chanakya, the Chandragupta's teacher and adviser, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life.[86][87]

According to the ancient Chinese Records of the Grand Historian, Luzhong, a sixth-generation descendant of the Yellow Emperor, had six sons, all born by "cutting open the body". The sixth son Jilian founded the House of Mi that ruled the State of Chu (c. 1030–223 BCE).[88]

In the Irish mythological text the Ulster Cycle, the character Furbaide Ferbend is said to have been born by posthumous caesarean section, after his mother was murdered by his evil aunt Medb.

The Babylonian Talmud, an ancient Jewish religious text, mentions a procedure similar to the caesarean section. The procedure is termed yotzei dofen.[87]

Pliny the Elder theorized that Julius Caesar's name came from an ancestor who was born by caesarean section, but the truth of this is debated (see the discussion of the etymology of Caesar). The Ancient Roman caesarean section was first performed to remove a baby from the womb of a mother who died during childbirth. Julius Caesar's mother, Aurelia, lived through childbirth and successfully gave birth to her son, ruling out the possibility the Roman ruler and general was born by caesarean section. His first wife however died in childbirth, giving birth to a stilborn son who might have lived had a caesarean taken place.

The Catalan saint Raymond Nonnatus (1204–1240), received his surname—from the Latin non-natus ("not born")—because he was born by caesarean section. His mother died while giving birth to him.[89]

An early account of caesarean section in Iran is mentioned in the book of Shahnameh, written around 1000 AD, and relates to the birth of Rostam, the national legendary hero of Iran.[90][91] According to the Shahnameh, the Simurgh instructed Zal upon how to perform a Caesarean section, thus saving Rudaba and the child Rostam.[92]

Caesarean section usually resulted in the death of the mother; the first well-recorded incident of a woman surviving a caesarean section was in the 1580s, in Siegershausen, Switzerland: Jakob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labour.[93] However, there is some basis for supposing that women regularly survived the operation in Roman times.[94] For most of the time since the 16th century, the procedure had a high mortality rate. However, it was long considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. In Great Britain and Ireland, the mortality rate in 1865 was 85%. Key steps in reducing mortality were:

European travelers in the Great Lakes region of Africa during the 19th century observed Caesarean sections being performed on a regular basis.[95] The expectant mother was normally anesthetized with alcohol, and herbal mixtures were used to encourage healing. From the well-developed nature of the procedures employed, European observers concluded they had been employed for some time.[95] Dr. James Barry carried out the first successful Caesarean by a European doctor in Africa in Cape Town, while posted there between 1817 and 1828.[96]

The first successful Caesarean section to be performed in America took place in what was formerly Mason County, Virginia (now Mason County, West Virginia), in 1794. The procedure was performed by Dr. Jesse Bennett on his wife Elizabeth.[97]

On March 5, 2000, in Mexico, Inés Ramírez performed a Caesarean section on herself and survived, as did her son, Orlando Ruiz Ramírez.[98] She is believed to be the only woman to have performed a successful Caesarean section on herself.[citation needed]

Society and culture

Etymology

The Roman Lex Regia (royal law), later the Lex Caesarea (imperial law), of Numa Pompilius (715–673 BCE),[99] required the child of a mother dead in childbirth to be cut from her womb.[100] There was a cultural taboo that mothers not be buried pregnant,[101] that may have reflected a way of saving some fetuses. Roman practice requiring a living mother to be in her tenth month of pregnancy before resorting to the procedure, reflecting the knowledge that she could not survive the delivery.[102] Speculation that the Roman dictator Julius Caesar was born by the method now known as C-section is apparently false.[103] Although Caesarean sections were performed in Roman times, no classical source records a mother surviving such a delivery.[100][104] As late as the 12th century, scholar and physician Maimonides expresses doubt over the possibility of a woman's surviving this procedure and again falling pregnant (see Commentary to Mishnah Bekhorot 8:2).[citation needed] The term has also been explained as deriving from the verb caedere, "to cut", with children delivered this way referred to as caesones. Pliny the Elder refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, "cut from the womb" giving this as an explanation for the cognomen "Caesar" which was then carried by his descendents.[100] Nonetheless, even if the etymological hypothesis linking the caesarean section to Julius Caesar is a false etymology, it has been widely believed. For example, the Oxford English Dictionary defines Caesarean birth as "the delivery of a child by cutting through the walls of the abdomen when delivery cannot take place in the natural way, as was done in the case of Julius Caesar".[105] Merriam-Webster's Collegiate Dictionary (11th edition) leaves room for etymological uncertainty with the phrase, "from the legendary association of such a delivery with the Roman cognomen Caesar"[106]

Some link with Julius Caesar or with Roman emperors exists in other languages as well. For example, the modern German, Norwegian, Danish, Dutch, Swedish, Turkish and Hungarian terms are respectively Kaiserschnitt, keisersnitt, kejsersnit,keizersnede, kejsarsnitt, sezaryen, and császármetszés (literally: "Emperor's cut").[107] The German term has also been imported into Japanese (帝王切開 teiōsekkai) and Korean (제왕 절개 jewang jeolgae), both literally meaning "emperor incision". Similar in western Slavic (Polish) cięcie cesarskie, (Czech) císařský řez and (Slovak) cisársky rez (literally "imperial cut"), whereas the south Slavic term is Serbian царски рез and Slovenian cárski réz, which literally means "tzar" cut. The Russian term kesarevo secheniye (Кесарево сечение késarevo sečénije) literally means Caesar's section. The Arabic term (ولادة قيصرية wilaada qaySaríyya) also means "Caesarean birth." The Hebrew term ניתוח קיסרי (nitúakh Keisári) translates literally as Caesarean surgery. In Romania and Portugal,[108] it is usually called cesariana, meaning from (or related to) Caesar.[citation needed]

According to Shahnameh ancient Persian book, the hero Rostam was the first person who was born with this method and term رستمينه (rostamineh) is corresponded to Caesarean.[citation needed] Also, Hindu mythical monkey god Hanuman was born through a similar procedure on his mother Anjani.

Finally, the Roman praenomen (given name) Caeso was said to be given to children who were born via C-section. While this was probably just folk etymology made popular by Pliny the Elder, it was well known by the time the term came into common use.[109]

Orthography

The term "Caesarean section" is spelled in many different ways.

One variation is the e/ae/æ variation which reflects American and British English spelling differences. Because some sources say the procedure is named after Julius Caesar, the procedure's name is sometimes capitalized. The capital-versus-lowercase variation reflects a style of lowercasing some eponymous terms (e.g., caesarean, eustachian, fallopian, mendelian, parkinsonian, parkinsonism).[110] Capital and lowercase stylings coexist in prevalent usage.

Because of (1) the e-vs-ae digraph variation, (2) the related ae-vs-æ typographic ligature variation, (3) the capital-vs-lowercase variation (which is based on the idea of eponymous origin, whether that is historically accurate or not; see eponym > orthographic conventions), and (4) the -ean-vs--ian suffix variation, these factors cross-multiplied in a table cause this word to be one of the very few words in present-day English orthography to have many different normative spellings or orthographic stylings, which amount to 12 from the point of view of character encoding (that is, there are 12 different character strings that are all accepted as normative orthographic representations of this one word):

Multiplication table
× C + e c + ae C + ae c + ae C + æ c + æ
ean Cesarean cesarean Caesarean caesarean Cæsarean cæsarean
ian Cesarian cesarian Caesarian caesarian Cæsarian cæsarian

Special populations

In Judaism there is a dispute among the poskim (Rabbinic authorities) as to whether a first-born son from a Caesarean section has the laws of a bechor.[111] Traditionally, a male child delivered by Caesarean is not eligible for the Pidyon HaBen dedication ritual.[112][113]

In rare cases, caesarean sections can be used to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a hysterotomy abortion and is very rarely performed.[citation needed]

Self-inflicted caesarean section is the concept of a mother alone performing her own caesarean section. There have apparently been a few successful cases, notably Inés Ramírez Pérez of Mexico who in March 2000, performed a successful Caesarean section on herself.[114][115]

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